Abstract
The objective of this study was to evaluate the utility of invasive and noninvasive diagnostic procedures in tuberculous pleurisy (TPE) in an area with intermediate incidence of tuberculosis. The aim was to determine the cutoff value for adenosine deaminase (ADA) and the sensitivity and specificity of ADA and evaluate pleural fluid cytology and pleural biopsy in the differential diagnosis of malignant and tuberculous pleurisy. The study included 121 patients. TPE was confirmed in 54 patients and malignant effusion in 67 patients. Criteria used for TPE diagnosis were positive cultures of effusion or biopsy specimen, tuberculous granulomas, or positive sputum cultures without other explanation for pleural effusion. Malignancy was diagnosed by either cytology or biopsy. The cutoff value of ADA in TPE was 49 U/L, sensitivity was 89.2%, specificity was 70.4%, positive predictive value (PPV) was 84.4%, and negative predictive value (NPV) was 78.4%. ADA activity below 16 U/L suggests that TPE is highly unlikely with sensitivity = 38.5%, specificity = 100%, PPV = 100%, and NPV = 57.4%. ADA effusion/serum ratio reached a cutoff in TPE of 1.7 (sensitivity = 84.6%, specificity = 72.2%, PPV = 81.4%, NPV = 71.4%). Sensitivity, specificity, PPV, and NPV of cytology evaluation for TPE are 72.2%, 70.1%, 66.1%, and 75.8%, respectively. Pleuroscopy-guided pleural biopsy had sensitivity = 66.7%, specificity = 100%, PPV = 100%, and NPV = 78.8%. In 27.8% of TPE cases, pleural fluid cultures were positive. There is no doubt that pleuroscopy-guided biopsy is of great value for TPE diagnosis; however, sensitivity and specificity of noninvasive tests, especially ADA, can help to distinguish between TB and malignancy.
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References
Valdes L, Pose A, SanJose E, Martinez Vasquez JM (2003) Tuberculous pleural effusions. Eur J Intern Med 14:77–88
Frank W (2002) Tuberculous pleural effusions. Eur Respir Mon 22:219–233
Jones JSP (2002) The pleura in health and disease. Lung 179:397–413
Giusti G (1974) Adenosine deaminase. In: Bergmeyer HU (ed) Methods of enzymatic analysis. Academic Press, New York, pp 1092–1096
Ilic M, Khan MI, Kuruc V, Pavlovic S (2003) Trends and patterns of tuberculosis: interpretations and prospects of tuberculosis control in Vojvodina, Yugoslavia, 1987–2000. Int J Tuberc Lung Dis 7(11):1064–1069
Vukelić A, Kurucin T, Kuruc V, Gvero D, Radaković D (2001) Drug susceptibility of Mycobacterium tuberculosis strains in patients with lung tuberculosis. Pneumon 39(1–4):65–71
Loddenkemper R, Boutin C (1993) Thoracoscopy: Diagnostic and therapeutic indications. Eur Respir J 6:1544–1555
Emad A, Rezaian G (1998) Diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: a comparative age dependent study. Respir Med 92:488–492
Diacon AH, Van de Wal BW, Wyser C, Smedema JP, Bezuidenhout J, Bolliger CT, Walzl G (2003) Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 22:589–591
Slazar-Lezama M, Torrentera RG, Bouscoulet L (2002) Comparison of adenosine deaminase levels in pleural fluid versus pleural biopsy, culture and smear in 124 consecutive patients with tuberculous pleural effusions. Chest 122(4):90S
Mahaveera PB, Shashirekha K, Choudhary RK (2003) Diagnostic yield of Mycobacterium in tuberculous pleural effusions: comparison of pleural specimens obtained by closed method with thoracoscopy. Chest 124(4):81S
Conde MB, Marinho SR, de Fatima Pereira M, Lapa e Silva JR, Saad MH, Sales CL, Ho JL, Kritski AL (2002) The usefulness of serum adenosine deaminase 2 (ADA2) activity in adults for the diagnosis of pulmonary tuberculosis. Respir Med 96:607–610
Perez Rodriguez E, Jimenez Castro D (2000) The use of adenosine deaminase and adenosine deaminase isoenzymes in the diagnosis of tuberculous pleuritis. Curr Opin Pulm Med 6:259–266
Venkatesh J, Kaur A, Zachariah A, Oommen A (1996) Molecular forms of adenosine deaminase do not aid the diagnosis of tuberculosis. Trans R Soc Trop Med Hyg 90:652–653
Ibrahim WH, Ghadban W, Khinji A, Yasin R, Soub H, Al-Khal AL, Bener A (2005) Does pleural tuberculosis disease pattern differ among developed and developing countries. Respir Med 99:1038–1045
Singh V, Kharb S, Ghalaut PS, Ashok J (1998) Serum adenosine deaminase activity in pleural effusion. Thorax 53(9):814
Bothamley GH (1995) Tuberculous pleurisy and adenosine deaminase. Thorax 50(6):593–594
Kataria YP, Khurshid I (2001) Adenosine deaminase in the diagnosis of tuberculous pleural effusion. Chest 120:334–336
Burgess L, Martiz F, Le Roux I, Taljaard JJF (1995) Use of adenosine deaminase as a diagnostic tool for tuberculous pleurisy. Thorax 50(6):672–674
Valdes L, Alvarez D, San Jose E, Juanatey JR, Pose A, Valle JM, Salgueiro M, Suárez JR (1995) Value of adenosine deaminase in the diagnosis of tuberculous pleural effusions in young patients in a region of high prevalence od tuberculosis. Thorax 50(6):600–603
Laniado-Laborin R (2005) Adenosine deaminase in the diagnosis of tuberculous effusion. Is it really an ideal test? A word of caution. Chest 127(2):417–418
Chen ML, Yu WC, Lam CW, Au KM, Kong FY, Wo Cham AY (2004) Diagnostic value of pleural fluid adenosine deaminase activity in tuberculous pleurisy. Clin Chim Acta 341:101–107
Valdes L, San Jose E, Alvarez D, Valle JM (1996) Adenosine deaminase (ADA) isoenzyme analysis in pleural effusions: diagnostic role, and relevance to the origin of increased ADA in tuberculous pleurisy. Eur Respir J 9:747–751
Jimenez Castro D, Diaz Nuevo G, Perez-Rodriguez E, Light RW (2003) Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J 21:220–224
Lee YCG, Rogers JT, Rodriguez RM, Miller KD, Light RW (2001) Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions. Chest 120:356–361
Ernam D, Atalay F, Hasanoglu HC, Kaplan O (2005) Role of biochemical tests in the diagnosis of exudative pleural effusions. Clin Biochem 38:19–23
Gorguner M, Cerci M, Gorguner I (2000) Determination of adenosine deaminase activity and its isoenzymes for diagnosis of pleural effusions. Respirology 5:321–324
Vats M, Gupta RC, Dadhich P, Vats D, Gupta N, Taylor M (2003) ADA assay in pleural fluids: a diagnostic tool in tuberculous pleural effusion. Chest 124(4):115S
Goto M, Noguchi Y, Koyama H, Hira K, Shimbo T, Fukui T (2003) Diagnostic value of adenosine deaminase in tuberculous pleural effusion: meta analysis. Ann Clin Biochem 40(4):374–381
Yildirim H, Metintas M, Ak G, Erginel S, Alatas F, Kurt E, Metintas S, Ucgun I (2007) Increased pleural fluid adenosine deaminase levels in patients with malignant pleural effusions: a potential predictor of talc pleurodesis outcome. Lung 185:349–354
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Zarić, B., Kuruc, V., Milovančev, A. et al. Differential Diagnosis of Tuberculous and Malignant Pleural Effusions: What is the Role of Adenosine Deaminase?. Lung 186, 233–240 (2008). https://doi.org/10.1007/s00408-008-9085-7
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DOI: https://doi.org/10.1007/s00408-008-9085-7